Valvular Heart Disease

Key Points

Table 1. The Heart Valve Team

RecommendationsCORLOE
Patients with severe VHD should be evaluated by a multidisciplinary Heart Valve Team when intervention
is considered.
IC
Consultation with or referral to a Heart Valve Center of Excellence is reasonable when discussing treatment options for
  • asymptomatic patients with severe VHD,
  • patients who may benefit from valve repair versus valve replacement, or
  • patients with multiple comorbidities for whom valve intervention is considered.
IIaC

Evaluation


Table 2. Stages of Progression of VHD

StageDefinitionDescription
AAt riskPatients with risk factors for development of VHD
BProgressivePatients with progressive VHD (mild-to-moderate severity and asymptomatic)
CAsymptomatic severeAsymptomatic patients who meet the criteria for severe VHD:
C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated
C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
DSymptomatic severePatients who have developed symptoms as a result of VHD

Table 3. Risk Assessment Combining STS Risk Estimate, Frailty, Major Organ System Dysfunction, and Procedure-Specific Impediments

 Low Risk
(Must Meet ALL Criteria in This Column)
Intermediate Risk
(Any 1 Criterion in This Column)
High Risk
(Any 1 Criterion in This Column)
Prohibitive Risk
(Any 1 Criterion in This Column)
STS PROMa<4%
AND
4%-8%
OR  
>8%
OR  
Predicted risk with surgery of death or major morbidity (all-cause) OR
FrailtybNone
AND  
1 index (mild)
OR  
≥2 indices (moderate to severe)
OR
>50% at 1 y
OR
Major organ system compromise not to be improved postoperativelycNone
AND  
1 organ system
OR  
No more than 2 organ systems
OR  
≥3 organ systems
OR
Procedure-specific impedimentdNonePossible procedure-specific impedimentPossible procedure-specific impedimentSevere procedure-specific impediment
a Use of the STS PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of STS average observed/expected ratio for the procedure in question.
b Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) and independence in ambulation (no walking aid or assist required or 5-meter walk in <6 s). Other scoring systems can be applied to calculate no, mild-, or moderate-to-severe frailty.
c Examples of major organ system compromise: Cardiac—severe LV systolic or diastolic dysfunction or RV dysfunction, fixed PHTN; CKD stage 3 or worse; pulmonary dysfunction with FEV1 <50% or DLCO2 <50% of predicted; CNS dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, stroke with persistent physical limitation); GI dysfunction—Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0; cancer—active malignancy; and liver—any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy.
d Examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, or radiation damage.

Table 4. Initial Diagnostic Testing

RecommendationsCORLOE
TTE is recommended in the initial evaluation of patients with known or suspected VHD to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences, determine prognosis, and evaluate for timing of intervention.IB
TTE is recommended in patients with known VHD with any change in symptoms or physical examination findings.IC
Periodic monitoring with TTE is recommended in asymptomatic patients with known VHD at intervals depending on valve lesion, severity, ventricular size, and ventricular function.IC
Cardiac catheterization for hemodynamic assessment is recommended in symptomatic patients when noninvasive tests are inconclusive or when there is a discrepancy between the findings on noninvasive testing and physical examination regarding severity of the valve lesion.IC
Exercise testing is reasonable in selected patients with asymptomatic severe VHD to
  • confirm the absence of symptoms, or
  • assess the hemodynamic response to exercise, or
  • determine prognosis.
IIaB

Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function

 Valve Lesion
StageASaARMSMR
Progressive (stage B)Every 3-5 y (mild severity: Vmax 2.0-2.9 m/s)
Every 1-2 y (moderate severity: Vmax
3.0-3.9 m/s)
Every 3-5 y (mild severity) Every 1-2 y (moderate severity)Every 3-5 y (MVA >1.5 cm2)Every 3-5 y (mild severity) Every 1-2 y (moderate severity)
Severe (stage C)Every 6-12 mo (Vmax ≥4 m/s)Every 6-12 mo Dilating LV: more frequentlyEvery 1-2 y (MVA 1.0-1.5 cm2) Once every year (MVA <1.0 cm2)Every 6-12 mo Dilating LV:
more frequently
Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single valve lesions.
a With normal stroke volume.

Rheumatic Fever


Table 6. Secondary Prevention of Rheumatic Fever

RecommendationsCORLOE
Secondary prevention of rheumatic fever is indicated in patients with rheumatic heart disease, specifically MS (Tables 7-8).IC

Table 7. Agents for Secondary Prevention of Rheumatic Fever

AgentDosage
Penicillin G benzathine1.2 million units IM every 4 wka
Penicillin V potassium250 mg orally BID
Sulfadiazine1 g orally QD
Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)bVaries
a Administration every 3 wk is recommended in certain high-risk situations.
b Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors.
Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551.

Table 8. Duration of Secondary Prophylaxis for Rheumatic Fever

TypeDuration After Last Attack
Rheumatic fever with carditis and residual heart disease (persistent VHDa)10 y or until patient is 40 y of age (whichever is longer)
Rheumatic fever with carditis but no residual heart disease (no valvular diseasea)10 y or until patient is 21 y of age (whichever is longer)
Rheumatic fever without carditis5 y or until patient is 21 y of age (whichever is longer)
a Clinical or echocardiographic evidence.
Adapted with permission from Gerber et al. Circulation. 2009;119:1541-1551.

Aortic Stenosis


Table 9. Stages of Valvular AS

StageDefinitionValve AnatomyValve HemodynamicsHemodynamic ConsequencesSymptoms
AAt risk of AS
  • Bicuspid aortic valve (or other congenital valve anomaly)
  • Aortic valve sclerosis
Aortic Vmax <2 m/sNoneNone
BProgressive AS
  • Mild-to-moderate leaflet calcification of a bicuspid or trileaflet valve with some reduction in systolic motion or
  • Rheumatic valve changes with commissural fusion
  • Mild AS:
    Aortic Vmax 2.0-2.9 m/s or ∆Pmean <20 mm Hg
  • Moderate AS:
    Aortic Vmax 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg
  • Early LV diastolic dysfunction may be present
  • Normal LVEF
  •  
None
C: Asymptomatic severe AS
C1Asymptomatic severe ASSevere leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥4 m/s or
    ∆Pmean ≥40 mm Hg
  • AVA typically ≤1.0 cm2
    (or AVAi ≤0.6 cm2/m2)
  • Very severe AS:
    Aortic Vmax ≥5 m/s or
    ∆Pmean ≥60 mm Hg
  • LV diastolic dysfunction
  • Mild LV hypertrophy
  • Normal LVEF
  •  
None: Exercise testing is reasonable to confirm symptom status
C2Asymptomatic severe AS with LV dysfunctionSevere leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥4 m/s or
    ∆Pmean ≥40 mm Hg
  • AVA typically ≤1.0 cm2
    (or AVAi ≤0.6 cm2/m2)
LVEF <50%None
D: Symptomatic severe AS
D1Symptomatic severe high-
gradient AS
Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening
  • Aortic Vmax ≥4 m/s or
    ∆Pmean ≥40 mm Hg
  • AVA typically ≤1.0 cm2 (or AVAi ≤0.6 cm2/m2) but may be larger with mixed AS/AR
  • LV diastolic dysfunction
  • LV hypertrophy
  • PHTN may be present
  •  
  • Exertional dyspnea or decreased exercise tolerance
  • Exertional angina
  • Exertional syncope or presyncope
D2Symptomatic severe low-flow/low-gradient AS with reduced LVEFSevere leaflet calcification with severely reduced leaflet motion
  • AVA ≤1.0 cm2 with resting aortic Vmax <4 m/s
    or ∆Pmean <40 mm Hg
  • DSE shows AVA ≤1.0 cm2 with Vmax ≥4 m/s at any flow rate
  • LV diastolic dysfunction
  • LV hypertrophy
  • LVEF <50%
  •  
  • HF
  • Angina
  • Syncope or presyncope
  •  
D3Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe ASSevere leaflet calcification with severely reduced leaflet motion
  • AVA ≤1.0 cm2 with
    aortic Vmax <4 m/s or
    ∆Pmean <40 mm Hg
  • Indexed AVA ≤0.6 cm2/m2 and
  • Stroke volume index
    <35 mL/m2
  • Measured when patient is normotensive (systolic BP <140 mm Hg)
  • Increased LV relative wall thickness
  • Small LV chamber with low stroke volume
  • Restrictive diastolic filling
  • LVEF ≥50%
  •  
  • HF
  • Angina
  • Syncope or presyncope
  •  

Table 10. Evaluation and Treatment in Patients With AS

RecommendationsCORLOE
Diagnostic Testing
TTE is indicated in patients with signs or symptoms of AS or a bicuspid aortic valve for accurate diagnosis of the cause of AS, hemodynamic severity, LV size and systolic function, and for determining prognosis and timing of valve intervention.IB
Low-dose dobutamine stress testing using echocardiographic or invasive hemodynamic measurements is reasonable in patients with stage D2 AS with all of the following:
  • Calcified aortic valve with reduced systolic opening;
  • LVEF <50%;
  • Calculated valve area ≤1.0 cm2; and
  • Aortic velocity <4.0 m/s or ∆Pmean <40 mm Hg.
IB
Exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms in asymptomatic patients with a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg (stage C).IIaB
Exercise testing should NOT be performed in symptomatic patients with AS when the aortic velocity is ≥4.0 m/s or ∆Pmean is ≥40 mm Hg (stage D).III: HarmB
Medical Therapy
Hypertension in patients at risk for developing AS (stage A) and in patients with asymptomatic AS (stages B and C) should be treated according to standard GDMT, started at a low dose and gradually titrated upward as needed with frequent clinical monitoring.IB
Vasodilator therapy may be reasonable if used with invasive hemodynamic monitoring in the acute management of patients with severe decompensated AS (stage D) with NYHA class IV HF symptoms.IIbC
Statin therapy is NOT indicated for prevention of hemodynamic progression of AS in patients with mild-to-moderate calcific valve disease (stages B-D).III: No BenefitA

Table 11. Indications for AVR in Patients With AS

RecommendationsCORLOE
AVR is recommended in symptomatic patients with severe AS (stage D1) with:
  • Decreased systolic opening of a calcified or congenitally stenotic aortic valve; and
  • Aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg; and
  • Symptoms of HF, syncope, exertional dyspnea, angina, or presyncope by history or on exercise testing.
IB
AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF <50% with decreased systolic opening of a calcified aortic valve with an aortic velocity
≥4.0 m/s or ∆Pmean ≥40 mm Hg.
IB
AVR is indicated for patients with very severe AS (stage C or D) when undergoing cardiac surgery for other indications when there is decreased systolic opening of a calcified aortic valve and aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg.IB
AVR is reasonable for asymptomatic patients with severe AS (stage C1) with:
  • Decreased systolic opening of a calcified valve;
  • Aortic velocity ≥5.0 m/s or ∆Pmean ≥60 mm Hg;
  • Low surgical risk.
IIaB
AVR is reasonable in apparently asymptomatic patients with severe AS (stage C1) with:
  • A calcified aortic valve;
  • Aortic velocity 4.0-4.9 m/s or ∆Pmean of
    40-59 mm Hg;
  • An exercise test demonstrating decreased exercise tolerance or a fall in systolic BP.
IIaB
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a:
  • Calcified aortic valve with reduced systolic opening;
  • Resting valve area ≤1.0 cm2;
  • Aortic velocity <4 m/s or ∆Pmean<40 mm Hg;
  • LVEF <50%; and
  • Low-dose dobutamine stress study that shows aortic velocity ≥4 m/s or ∆Pmean ≥40 mm Hg with valve area ≤1.0 cm2 at any dobutamine dose.
IIaB
AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS (stage D3) with LVEF ≥50%, a calcified aortic valve with significantly reduced leaflet motion, and a valve area ≤1.0 cm2 only if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms and data recorded when the patient is normotensive (systolic BP <140 mm Hg) indicate:
  • An aortic velocity <4 m/s or ∆Pmean <40 mm Hg;
  • A stroke volume index <35 mL/m2; and
  • An indexed valve area ≤0.6 cm2/m2.
IIaC
AVR is reasonable for patients with moderate AS (stage B) with an aortic velocity 3.0-3.9 m/s or ∆Pmean 20-39 mm Hg who are undergoing cardiac surgery for other indications.IIaC
AVR may be considered for asymptomatic patients with
severe AS (stage C1) with aortic velocity ≥4.0 m/s or ∆Pmean ≥40 mm Hg if the patient is at low surgical risk and serial testing shows an increase in aortic velocity ≥0.3 m/s/y.
IIbC

Table 12. Choice of Intervention in Patients With AS

RecommendationsCORLOE
Surgical AVR is recommended in patients who meet an indication for AVR with low or intermediate surgical risk.IA
For patients in whom TAVR or high-risk surgical AVR is being considered, a Heart Valve Team consisting of an integrated, multidisciplinary group of healthcare professionals with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should collaborate to provide optimal patient care.IC
TAVR is recommended in patients who meet an indication for AVR who have a prohibitive risk for surgical AVR and a predicted post-TAVR survival >12 months.IB
TAVR is a reasonable alternative to surgical AVR in patients who meet an indication for AVR and who have high surgical risk for surgical AVR.IIaB
Percutaneous aortic balloon dilation may be considered as a bridge to surgical AVR or TAVR in patients with severe symptomatic AS.IIbC
TAVR is NOT recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS.III: No BenefitB

Figure 1. Indications for AVR in Patients With AS


Table 13. Stages of Chronic AR

StageDefinitionValve AnatomyValve HemodynamicsHemodynamic ConsequencesSymptoms
AAt risk of AR
  • Bicuspid aortic valve (or other congenital valve anomaly)
  • Aortic valve sclerosis
  • Diseases of the aortic sinuses or ascending aorta
  • History of rheumatic fever or known rheumatic heart disease
  • IE
AR severity: none or traceNoneNone
BProgressive AR
  • Mild-to-moderate calcification of a trileaflet valve, bicuspid aortic valve (or other congenital valve anomaly)
  • Dilated aortic sinuses
  • Rheumatic valve changes
  • Previous IE

Mild AR:

  • Jet width <25% of LVOT;
  • Vena contracta <0.3 cm;
  • RVol <30 mL/beat;
  • RF <30%;
  • ERO <0.10 cm2;
  • Angiography grade 1+

Moderate AR:

  • Jet width 25%-64% of LVOT;
  • Vena contracta 0.3-0.6 cm;
  • RVol 30-59 mL/beat;
  • RF 30%-49%;
  • ERO 0.10-0.29 cm2;
  • Angiography grade 2+
  • Normal LV systolic function
  • Normal LV volume or mild LV dilation
None
CAsymptomatic severe AR
  • Calcific aortic valve disease
  • Bicuspid valve (or other
    congenital abnormality)
  • Dilated aortic sinuses or
    ascending aorta
  • Rheumatic valve changes
  • IE with abnormal leaflet closure or perforation

Severe AR:

  • Jet width ≥65% of LVOT;
  • Vena contracta >0.6 cm;
  • Holodiastolic flow reversal in the proximal abdominal aorta;
  • RVol ≥60 mL/beat;
  • RF ≥50%;
  • ERO ≥0.3 cm2;
  • Angiography grade 3+-4+;
  • In addition, diagnosis of chronic severe AR requires evidence of LV dilation

C1:

  • Normal LVEF (≥50%) and mild-to-moderate LV dilation (LVESD ≤50 mm)

C2:

  • Abnormal LV systolic function with depressed LVEF (<50%) or severe LV dilatation (LVESD >50 mm or indexed LVESD >25 mm/m2)
None; exercise testing is reasonable to confirm symptom status
DSymptomatic severe AR
  • Calcific valve disease
  • Bicuspid valve (or other
    congenital abnormality)
  • Dilated aortic sinuses or
    ascending aorta
  • Rheumatic valve changes
  • Previous IE with abnormal leaflet closure or perforation

Severe AR:

  • Doppler jet width ≥65% of LVOT;
  • Vena contracta >0.6 cm;
  • Holodiastolic flow reversal in the proximal abdominal aorta;
  • RVol ≥60 mL/beat;
  • RF ≥50%;
  • ERO ≥0.3 cm2;
  • Angiography grade 3+-4+;
  • In addition, diagnosis of chronic severe AR requires evidence of
    LV dilation
  • Symptomatic severe AR may occur with normal systolic function (LVEF ≥50%), mild-to-moderate LV dysfunction (LVEF 40%-50%), or severe LV dysfunction (LVEF <40%)
  • Moderate-to-severe LV dilation
  • Exertional dyspnea or angina or more severe HF symptoms

Table 14. Diagnosis, Medical Therapy, and Intervention in Patients With Chronic AR

RecommendationsCORLOE
TTE is indicated in patients with signs or symptoms of AR (stages A-D) for accurate diagnosis of the cause of regurgitation, regurgitant severity, and LV size and systolic function, and for determining clinical outcome and timing of valve intervention.IB
TTE is indicated in patients with dilated aortic sinuses or ascending aorta or with a bicuspid aortic valve (stages A and B) to evaluate the presence and severity of AR.IB
CMR is indicated in patients with moderate or severe AR (stages B-D) and suboptimal echocardiographic images for the assessment of LV systolic function, systolic and diastolic volumes, and measurement of AR severity.IB
Medical Therapy
Treatment of hypertension (systolic BP >140 mm Hg) is recommended in patients with chronic AR (stages B and C), preferably with dihydropyridine calcium channel blockers or ACE inhibitors/ARBs.IB
Medical therapy with ACE inhibitors/ARBs and beta blockers is reasonable in patients with severe AR who have symptoms and/or LV dysfunction (stages C2 and D) when surgery is not performed because of comorbidities.IIaB
Surgical Intervention
AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D).IB
AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF <50%) at rest (stage C2) if no other cause for systolic dysfunction is identified.IB
AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications.IC
AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥50%) but with severe LV dilation (LVESD >50 mm or indexed LVESD >25 mm/m2) (stage C2).IIaB
AVR is reasonable in patients with moderate AR (stage B) while undergoing surgery on the ascending aorta, CABG, or MV surgery.IIaC
AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF ≥50%, stage C1) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low.IIbC

Figure 2. Indications for AVR for Chronic AR


Bicuspid Aortic Valve and Aortopathy


Table 15. Diagnosis and Intervention in Patients With Bicuspid Aortic Valve and Aortopathy

RecommendationsCORLOE
Diagnosis
An initial TTE is indicated in patients with a known bicuspid aortic valve to evaluate valve morphology, to measure the severity of AS and AR, and to assess the shape and diameter of the aortic sinuses and ascending aorta for prediction of clinical outcome and to determine timing of intervention.IB
Aortic magnetic resonance angiography or CT angiography is indicated in patients with a bicuspid aortic valve when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography.IC
Serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is recommended in patients with a bicuspid aortic valve and an aortic diameter >4.0 cm, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history. In patients with an aortic diameter >4.5 cm, this evaluation should be performed annually.IC
Surgical Intervention
Operative intervention to repair the aortic sinuses or replace the ascending aorta is indicated in patients with a bicuspid aortic valve if the diameter of the aortic sinuses or ascending aorta is >5.5 cmIB
Operative intervention to repair the aortic sinuses or replace the ascending aorta is reasonable in patients with bicuspid aortic valves if the diameter of the aortic sinuses or ascending aorta is >5.0 cm and a risk factor for dissection is present (family history of aortic dissection or if the rate of increase in diameter ≥0.5 cm per year).IIaC
Replacement of the ascending aorta is reasonable in patients with a bicuspid aortic valve who are undergoing aortic valve surgery because of severe AS or AR if the diameter of the ascending aorta is >4.5 cm.IIaC

Mitral Stenosis


Figure 3. Indications for Intervention in Patients With Rheumatic MS


Table 16. Stages of MS

StageDefinitionValve AnatomyValve HemodynamicsaHemodynamic ConsequencesSymptoms
AAt risk of MS
  • Mild valve doming during diastole
Normal transmitral flow velocityNoneNone
BProgressive MS
  • Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets
  • Planimetered MVA >1.5 cm2
  • Increased transmitral flow velocities
  • MVA >1.5 cm2
  • Diastolic pressure half-time <150 ms
  • Mild-to-moderate LA enlargement
  • Normal pulmonary pressure at rest
None
CAsymptomatic severe MS
  • Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets
  • Planimetered MVA ≤1.5 cm2
  • (MVA ≤1.0 cm2 with very severe MS)
  • MVA ≤1.5 cm2
    (MVA ≤1.0 cm2 with severe MS)
  • Diastolic pressure half-time ≥150 ms (Diastolic pressure half-time ≥220 ms with severe MS)
  • Severe LA enlargement
  • Elevated PASP >30 mm Hg
None
DSymptomatic severe MS
  • Rheumatic valve changes with commissural fusion and diastolic doming of the MV leaflets
  • Planimetered MVA ≤1.5 cm2
  • MVA ≤1.5 cm2
    (MVA ≤1.0 cm2 with very severe MS)
  • Diastolic pressure half-time ≥150 ms
    (Diastolic pressure half-time ≥220 ms with very severe MS)
  • Severe LA enlargement
  • Elevated PASP >30 mm Hg
  • Decreased exercise tolerance
  • Exertional dyspnea
a The transmitral ΔP mean should be obtained to further determine the hemodynamic effect of the MS and is usually >5-10 mm Hg in severe MS. However, due to the variability of the ΔPmean with heart rate and forward flow, it has not been included in the criteria for severity.

Table 17A. Diagnosis and Medical Therapy in Patients With MS

RecommendationsCORLOE
TTE is indicated in patients with signs or symptoms of MS to establish the diagnosis, quantify hemodynamic severity (ΔPmean, MVA, and PA pressure), assess concomitant valvular lesions, and demonstrate valve morphology (to determine suitability for mitral commissurotomy).IB
TEE should be performed in patients considered for PMBC to assess the presence or absence of left atrial thrombus and to further evaluate the severity of MR.IB
Exercise testing with Doppler or invasive hemodynamic assessment is recommended to evaluate the response of the mean mitral gradient and PA pressure in patients with MS when there is a discrepancy between resting Doppler echocardiographic findings and clinical symptoms or signs.IC
Anticoagulation (VKA or heparin) is indicated in patients with
  • MS and AF (paroxysmal, persistent, or permanent), or
  • MS and a prior embolic event, or
  • MS and a left atrial thrombus.
IB
Heart rate control can be beneficial in patients with MS and AF and fast ventricular response.IIaC
Heart rate control may be considered for patients with MS in normal sinus rhythm and symptoms associated with exercise.IIbB

Table 17B. Intervention in Patients With MS

RecommendationsCORLOE
PMBC is recommended for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR.IA
MV surgery (repair, commissurotomy, or valve replacement) is indicated in severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who are not high risk for surgery and who are not candidates for or who have failed previous PMBC.IB
Concomitant MV surgery is indicated for patients with severe MS (MVA ≤1.5 cm2, stage C or D) undergoing cardiac surgery for other indications.IC
PMBC is reasonable for asymptomatic patients with very severe MS (MVA ≤1.0 cm2, stage C) and favorable valve morphology in the absence of left atrial thrombus or moderate-to-severe MR.IIaC
MV surgery is reasonable for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D), provided there are other operative indications (eg, aortic valve disease, CAD, TR, aortic aneurysm).IIaC
PMBC may be considered for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C) and valve morphology favorable for PMBC in the absence of left atrial thrombus or moderate-to-severe MR who have new onset of AF.IIbC
PMBC may be considered for symptomatic patients with MVA >1.5 cm2 if there is evidence of hemodynamically significant MS based on PAWP >25 mm Hg or mean MV gradient >15 mm Hg during exercise.IIbC
PMBC may be considered for severely symptomatic patients (NYHA class III-IV) with severe MS (MVA ≤1.5 cm2, stage D) who have suboptimal valve anatomy and who are not candidates for surgery or are at high risk for surgery.IIbC
Concomitant MV surgery may be considered for patients with moderate MS (MVA 1.6-2.0 cm2) undergoing cardiac surgery for other indications.IIbC
MV surgery and excision of the left atrial appendage may be considered for patients with severe MS (MVA ≤1.5 cm2, stages C and D) who have had recurrent embolic events while receiving adequate anticoagulation.IIbC

Table 18A. Stages of Primary MR

StageDefinitionValve AnatomyValve HemodynamicsaHemodynamic ConsequencesSymptoms
AAt risk of MR
  • Mild MV prolapse with normal coaptation
  • Mild valve thickening and leaflet restriction
  • No MR jet or small central jet area <20% LA on Doppler
  • Small vena contracta <0.3 cm
NoneNone
BProgressive MR
  • Severe MV prolapse with normal coaptation
  • Rheumatic valve changes with leaflet restriction and loss of central coaptation
  • Prior IE
  • Central jet MR 20%-40% LA or
    late systolic eccentric jet MR
  • Vena contracta <0.7 cm
  • RVol <60 mL
  • RF <50%
  • ERO <0.40 cm2
  • Angiographic grade 1+-2+
  • Mild LA enlargement
  • No LV enlargement
  • Normal pulmonary pressure
None
CAsymptomatic severe MR
  • Severe MV prolapse with loss of coaptation or flail leaflet
  • Rheumatic valve changes with leaflet restriction and loss of central coaptation
  • Prior IE
  • Thickening of leaflets with radiation heart disease
  • Central jet MR >40% LA or holosystolic eccentric jet MR
  • Vena contracta ≥0.7 cm
  • RVol ≥60 mL
  • RF ≥50%
  • ERO ≥0.40 cm2
  • Angiographic grade 3+-4+
  • Moderate or severe LA enlargement
  • LV enlargement
  • PHTN may be present at rest or with exercise
  • C1: LVEF >60% and LVESD <40 mm
  • C2: LVEF ≤60% and LVESD ≥40 mm
None
DSymptomatic severe MR
  • Severe MV prolapse with loss of coaptation or flail leaflet
  • Rheumatic valve changes with leaflet restriction and loss of central coaptation
  • Prior IE
  • Thickening of leaflets with radiation heart disease
  • Central jet MR >40% LA or holosystolic eccentric jet MR
  • Vena contracta ≥0.7 cm
  • RVol ≥60 mL
  • RF ≥50%
  • ERO ≥0.40 cm2
  • Angiographic grade 3+-4+
  • Moderate or severe LA enlargement
  • LV enlargement
  • PHTN present
  • Decreased exercise tolerance
  • Exertional dyspnea
a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence.

Table 18B. Stages of Secondary MR

StageDefinitionValve AnatomyValve HemodynamicsaAssociated
Cardiac Findings
Symptoms
AAt risk of MR
  • Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy
  • No MR jet or small central jet area <20% LA on Doppler
  • Small vena contracta <0.30 cm
  • Normal or mildly dilated LV with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities
  • Primary myocardial disease with LV dilation and systolic dysfunction
Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
BProgressive MR
  • Regional wall motion abnormalities with mild tethering of mitral leaflet
  • Annular dilation with mild loss of central coaptation of the mitral leaflets
  • ERO <0.20 cm2 b
  • RVol <30 mL
  • RF <50%
  • Regional wall motion abnormalities with reduced LV systolic function
  • LV dilation and systolic dysfunction due to primary myocardial disease
Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
CAsymptomatic severe MR
  • Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet
  • Annular dilation with severe loss of central coaptation of the mitral leaflets
  • ERO ≥0.20 cm2 b
  • RVol ≥30 mL
  • RF ≥50%
  •  
  • Regional wall motion abnormalities with reduced LV systolic function
  • LV dilation and systolic dysfunction due to primary myocardial disease
Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
DSymptomatic severe MR
  • Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet
  • Annular dilation with severe loss of central coaptation of mitral leaflets
  • ERO ≥0.20 cm2 b
  • RVol ≥30 mL
  • RF ≥50%
  • Regional wall motion abnormalities with reduced LV systolic function
  • LV dilation and systolic dysfunction due to primary myocardial disease
  • HF symptoms due to MR persist even after revascularization and optimization of medical therapy
  • Decreased exercise tolerance
  • Exertional dyspnea
a Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence.
b
The measurement of the proximal isovelocity surface area by 2D TTE in patients with chronic secondary MR underestimates the true ERO due to the crescent shape of the proximal convergence.  

Table 19. Diagnosis and Medical Therapy in Patients With Chronic Primary MR

RecommendationsCORLOE
Diagnosis
TTE is indicated for baseline evaluation of LV size and function, RV function and LA size, PA pressure, and mechanism and severity of primary MR (stages A-D) in any patient suspected of having chronic primary MR.IB
CMR is indicated in patients with chronic primary MR to assess LV and RV volumes, function, or MR severity and when these issues are not satisfactorily addressed by TTE.IB
Intraoperative TEE is indicated to establish the anatomic basis for chronic primary MR (stages C and D) and to guide repair.IB
TEE is indicated for evaluation of patients with chronic primary MR (stages B-D) in whom noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of LV function.IC
Exercise hemodynamics with either Doppler echocardiography or cardiac catheterization is reasonable in symptomatic patients with chronic primary MR where there is a discrepancy between symptoms and severity of MR at rest (stages B and C).IIaB
Exercise treadmill testing can be useful in patients with chronic primary MR to establish symptom status and exercise tolerance (stages B and C).IIaC
Medical Therapy
Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR (stage D) and LVEF <60% in whom surgery is not contemplated.IIaB
Vasodilator therapy is NOT indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function.III: No BenefitB

Table 20. Intervention in Patients With Chronic Primary MR

RecommendationsCORLOE
MV surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF >30%.IB
MV surgery is recommended for asymptomatic patients
with chronic severe primary MR and LV dysfunction (LVEF 30%-60% and/or LVESD ≥40 mm, stage C2).
IB
MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet.IB
MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished.IB
Concomitant MV repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications.IB
MV repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <40 mm) in whom the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1% when performed at a Heart Valve Center of Excellence.IIaB
MV repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting PHTN (PA systolic arterial pressure >50 mm Hg).IIaB
Concomitant MV repair is reasonable in patients with chronic moderate primary MR (stage B) undergoing cardiac surgery for other indications.IIaC
MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF ≤30% (stage D).IIbC
MV repair may be considered in patients with rheumatic MV disease when surgical treatment is indicated if a durable and successful repair is likely or if the reliability of long-term anticoagulation management is questionable.IIbB
Transcatheter MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal GDMT for HF.IIbB
MVR should NOT be performed for treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful.III: HarmB

Table 21. Diagnosis and Treatment of Patients With Chronic Secondary MR

RecommendationsCORLOE
Diagnosis
TTE is useful to establish the etiology of chronic secondary MR (stages B-D) and the extent and location of wall motion abnormalities and to assess global LV function, severity of MR, and magnitude of PHTN.IC
Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B-D) and/or to assess myocardial viability, which in turn may influence management of functional MR.IC
Medical Therapy
Patients with chronic secondary MR (stages B-D) and HF with reduced LVEF should receive standard GDMT therapy for HF, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated.IA
CRT with biventricular pacing is recommended for symptomatic patients with chronic severe secondary MR (stages B-D) who meet the indications for device therapy.IA
Surgical Intervention
MV surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.IIaC
MV repair or replacement may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT for HF.IIbB
MV repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery.IIbC

Figure 4. Indications for Surgery for MR


TV Disease


Table 22. Stages of TR

StageDefinitionValve AnatomyValve HemodynamicsaHemodynamic ConsequencesSymptoms
AAt risk of TRPrimary:
  • Mild rheumatic change
  • Mild prolapse
  • Other (eg, IE with vegetation, early carcinoid deposition, radiation)
  • Intra-annular RV pacemaker or
    ICD lead
  • Postcardiac transplant (biopsy related)
Functional:
  • Normal
  • Early annular dilation
No or trace TRNoneNone or in relation to other left heart or pulmonary/pulmonary vascular disease
BProgressive TRPrimary:
  • Progressive leaflet deterioration/destruction
  • Moderate-to-severe prolapse, limited chordal rupture
Functional:
  • Early annular dilation
  • Moderate leaflet tethering
Mild TR:
  • Central jet area <5.0 cm2
  • Vena contracta width not defined
  • CW jet density and contour: soft and parabolic
  • Hepatic vein flow: systolic dominance
Moderate TR:
  • Central jet area 5-10 cm2
  • Vena contracta width not defined
    but <0.70 cm
  • CW jet density and contour: dense, variable contour
  • Hepatic vein flow: systolic blunting
Mild TR:
  • RV/RA/IVC size normal
      Moderate TR:
  • No RV enlargement
  • No or mild RA enlargement
  • No or mild IVC enlargement with normal respirophasic variation
  • Normal RA pressure
None or in relation to other left heart or pulmonary/pulmonary vascular disease
CAsymptomatic severe TRPrimary:
  • Flail or grossly distorted leaflets
Functional:
  • Severe annular dilation (>40 mm or 21 mm/m2)
  • Marked leaflet tethering
  • Central jet area >10.0 cm2
  • Vena contracta width >0.7 cm
  • CW jet density and contour:
    dense, triangular with early peak
  • Hepatic vein flow: systolic reversal
  • RV/RA/IVC dilated with decreased IVC respirophasic variation
  • Elevated RA pressure with “c-V” wave
  • Diastolic interventricular septal flattening may be present
None, or in relation to other left heart or pulmonary/pulmonary vascular disease
DSymptomatic severe TRPrimary:
  • Flail or grossly distorted leaflets
Functional:
  • Severe annular dilation (>40 mm or >21 mm/m2)
  • Marked leaflet tethering
  • Central jet area >10.0 cm2
  • Vena contracta width >0.70 cm
  • CW jet density and contour:
    dense, triangular with early peak
  • Hepatic vein flow: systolic reversal
  • RV/RA/IVC dilated with decreased IVC respirophasic variation
  • Elevated RA pressure with “c-V” wave
  • Diastolic interventricular septal flattening
  • Reduced RV systolic function in late phase
Fatigue, palpitations, dyspnea, abdominal bloating, anorexia, edema
a Several valve hemodynamic criteria are provided for assessment of severity of TR, but not all criteria for each category will necessarily be present in every patient. Categorization of severity of TR as mild, moderate, or severe also depends on image quality and integration of these parameters with clinical findings.

Table 23. Diagnosis, Medical Therapy, and Surgery in Patients With TR

RecommendationsCORLOE
Diagnosis
TTE is indicated to evaluate severity of TR, determine etiology, measure size of right-sided chambers and IVC, assess RV systolic function, estimate PASP, and characterize any associated left-sided heart disease.IC
Invasive measurement of PA pressures and pulmonary vascular resistance can be useful in patients with TR when clinical and noninvasive data regarding their values are discordant.IIaC
CMR or real-time 3D echocardiography may be considered for assessment of RV systolic function and systolic and diastolic volume in patients with severe TR (stages C and D) and suboptimal 2D echocardiograms.IIbC
Exercise testing may be considered for the assessment of exercise capacity in patients with severe TR with no or minimal symptoms (stage C).IIbC
Medical Therapy
Diuretics can be useful for patients with severe TR and signs of right-sided HF (stage D).IIaC
Medical therapies to reduce elevated PA pressures and/or pulmonary vascular resistance might be considered in patients with severe functional TR (stages C and D).IIbC
Surgery
TV surgery is recommended for patients with severe TR (stages C and D) undergoing left-sided valve surgery.IC
TV repair can be beneficial for patients with mild, moderate, or greater functional TR (stage B) at the time of left-sided valve surgery with either 1) TA dilation or 2) prior evidence of right HF.IIaB
TV surgery can be beneficial for patients with symptoms due to severe primary TR that are unresponsive to medical therapy (stage D).IIaC
TV repair may be considered for patients with moderate functional TR (stage B) and PHTN at the time of left-sided valve surgery.IIbC
TV surgery may be considered for asymptomatic or minimally symptomatic patients with severe primary TR (stage C) and progressive degrees of moderate or greater RV dilation and/or systolic dysfunction.IIbC
Reoperation for isolated TV repair or replacement may be considered for persistent symptoms due to severe TR (stage D) in patients who have undergone previous left-sided valve surgery and who do not have severe PHTN or significant RV systolic dysfunction.IIbC

Figure 5. Indications for Surgery in Patients With TR


Tricuspid Stenosis


Table 24. Stages of Severe TS

StageDefinitionValve AnatomyValve HemodynamicsHemodynamic ConsequencesSymptoms
C, DSevere TSThickened, distorted, calcified leaflets
  • T½ ≥190 ms
  • Valve area ≤1.0 cm2
RA/IVC enlargementNone or variable and dependent on severity of associated valve disease and degree of obstruction
The transtricuspid diastolic gradient is highly variable and is affected by heart rate, forward flow, and phases of the respiratory cycle. However, severe TS usually has ∆Pmeans >5-10 mm Hg at heart rate 70.

Table 25. Diagnosis and Intervention in Patients With TS

RecommendationsCORLOE
Diagnosis
TTE is indicated in patients with TS to assess the anatomy of the valve complex, evaluate severity of stenosis, and characterize any associated regurgitation and/or left-sided valve disease.IC
Invasive hemodynamic assessment of severity of TS may be considered in symptomatic patients when clinical and noninvasive data are discordant.IIbC
Intervention
TV surgery is recommended for patients with severe TS at the time of operation for left-sided valve disease.IC
TV surgery is recommended for patients with isolated, symptomatic severe TS.IC
Percutaneous balloon tricuspid commissurotomy might be considered in patients with isolated, symptomatic severe TS without accompanying TR.IIbC

Pulmonic Valve Disease


Table 26. Stages of Severe PR

StageDefinitionValve AnatomyValve HemodynamicsHemodynamic ConsequencesSymptoms
C, DSevere PRDistorted or absent leaflets, annular dilation
  • Color jet fills RVOT
  • CW jet density and contour: dense laminar flow with steep deceleration slope; may terminate abruptly
  • Paradoxical septal motion (volume overload pattern)
  • RV enlargement
None or variable and dependent on cause of PR and RV function

Table 27. Stages of Severe PS

StageDefinitionValve AnatomyValve HemodynamicsHemodynamic ConsequencesSymptoms
C, DSevere PS
  • Thickened, distorted, possibly calcified leaflets with systolic doming and/or reduced excursion
  • Other anatomic abnormalities may be present, such as narrowed RVOT
Vmax >4 m/s;
peak instantaneous gradient
>64 mm Hg
  • RVH
  • Possible RV, RA enlargement
  • Poststenotic enlargement of main PA
  •  
None or variable and dependent on severity of obstruction

Prosthetic Valves


Table 28. Diagnosis and Anticoagulation for Prosthetic Valves

RecommendationsCORLOE
Diagnosis
An initial TTE study is recommended in patients after prosthetic valve implantation for evaluation of valve hemodynamics.IB
Repeat TTE is recommended in patients with prosthetic heart valves if there is a change in clinical symptoms or signs suggesting valve dysfunction.IC
TEE is recommended when clinical symptoms or signs suggest prosthetic valve dysfunction.IC
Annual TTE is reasonable in patients with a bioprosthetic valve after the first 10 years, even in the absence of a change in clinical status.IIaC
Antithrombotic Therapy
Anticoagulation with a VKA and INR monitoring is recommended in patients with a mechanical prosthetic valve.IA
Anticoagulation with a VKA to achieve an INR of 2.5 is recommended in patients with a mechanical AVR (bileaflet or current-generation single tilting disc) and no risk factors for thromboembolism.IB
Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical AVR and additional risk factors for thromboembolic events (AF, previous thromboembolism, LV dysfunction, or hypercoagulable conditions) or an older-generation mechanical AVR (such as ball-in-cage).IB
Anticoagulation with a VKA is indicated to achieve an INR of 3.0 in patients with a mechanical MVR.IB
ASA 75-100 mg daily is recommended in addition to anticoagulation with a VKA in patients with a mechanical valve prosthesis.IA
ASA 75-100 mg daily is reasonable in all patients with a bioprosthetic aortic or MV.IIaB
Anticoagulation with a VKA is reasonable for the first 3 months after bioprosthetic MVR or repair to achieve an INR of 2.5.IIaC
Anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for the first 3 months after bioprosthetic AVR.IIbB
Clopidogrel 75 mg daily may be reasonable for the first
6 months after TAVR in addition to lifelong ASA
75-100 mg daily.
IIbC
Anticoagulant therapy with oral direct thrombin inhibitors or anti-Xa agents should NOT be used in patients with mechanical valve prostheses.III: HarmB
Bridging Therapy
Continuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.IC
Temporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures.IC
Bridging anticoagulation with either IV UFH or SC LMWH is recommended during the time interval when the INR is subtherapeutic preoperatively in patients who are undergoing invasive or surgical procedures with a 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical MVR.IC
Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures.IIaC
Administration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves and uncontrollable bleeding who require reversal of anticoagulation.IIaB

Table 29. Prosthetic Valve Choice

RecommendationsCORLOE
The choice of valve intervention, that is, repair or replacement, as well as type of prosthetic heart valve, should be a shared decision-making process that accounts for the patient’s values and preferences, with full disclosure of the indications for and risks of anticoagulant therapy and the potential need for and risk of reoperation.IC
A bioprosthesis is recommended in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.IC
A mechanical prosthesis is reasonable for AVR or MVR in patients <60 y of age who do not have a contraindication to anticoagulation.IIaB
A bioprosthesis is reasonable in patients >70 y of age.IIaB
Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 y of age.IIaB
Replacement of the aortic valve by a pulmonary autograft (the Ross procedure), when performed by an experienced surgeon, may be considered in young patients when VKA anticoagulation is contraindicated or undesirable.IIbC

Figure 6. Anticoagulation for Prosthetic Valves


Figure 7. Evaluation and Management of Suspected Prosthetic Valve Thrombosis


Table 30. Prosthetic Valve Complications

Recommendations  
Prosthetic Valve Thrombosis
TTE is indicated in patients with suspected prosthetic valve thrombosis to assess hemodynamic severity and follow resolution of valve dysfunction.IB
TEE is indicated in patients with suspected prosthetic valve thrombosis to assess thrombus size and valve motion.IB
Fluoroscopy or CT is reasonable in patients with suspected valve thrombosis to assess valve motion.IIaC
Fibrinolytic therapy is reasonable for patients with a thrombosed left-sided prosthetic heart valve, recent onset (<14 days) of NYHA class I-II symptoms, and a small thrombus (<0.8 cm2).IIaB
Fibrinolytic therapy is reasonable for thrombosed right-sided prosthetic heart valves.IIaB
Emergency surgery is recommended for patients with a thrombosed left-sided prosthetic heart valve with NYHA
class III-IV symptoms.
IB
Emergency surgery is reasonable for patients with a thrombosed left-sided prosthetic heart valve with a mobile
or large thrombus (>0.8 cm2).
IIaC
Prosthetic Valve Stenosis
Repeat valve replacement is indicated for severe symptomatic prosthetic valve stenosis.IC
Prosthetic Valve Regurgitation
Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation.IB
Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation.IIaC
Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure.IIaB

Infectious Endocarditis


Figure 8. Recommendations for Imaging Studies in NVE and PVE


Figure 9. Diagnosis and Treatment of IE


Table 31A. Prophylaxis of IE

RecommendationsCORLOE
Prophylaxis
Prophylaxis against IE is reasonable for the following patients at highest risk for adverse outcomes from IE before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa:
  • Patients with prosthetic cardiac valves;
  • Patients with previous IE;
  • Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve; or
  • Patients with congenital heart disease:
    • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits;
    • Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure;
    • Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.
IIaB
Prophylaxis against IE is NOT recommended in patients with VHD who are at risk of IE for nondental procedures (eg, TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.III: No BenefitB

Table 31B. Diagnosis and Treatment of IE

RecommendationsCORLOE
Diagnosis
At least 2 sets of blood cultures should be obtained in patients at risk for IE (eg, those with congenital or acquired VHD, previous IE, prosthetic heart valves, certain congenital or heritable heart malformations, immunodeficiency states, or injection drug users) who have unexplained fever for more than 48 hoursIB
or patients with newly diagnosed left-sided valve regurgitation.IC
The Modified Duke Criteria should be used in evaluating a patient with suspected IE (Tables 32-33).IB
Cardiac CT is reasonable to evaluate morphology/anatomy in the setting of suspected paravalvular infections when the anatomy cannot be clearly delineated by echocardiography.IIaB
TEE & TTE
TTE is recommended in patients with suspected IE to identify vegetations, characterize the hemodynamic severity of valvular lesions, assess ventricular function and pulmonary pressures, and detect complications.IB
TEE is recommended in all patients with known or suspected IE when TTE is nondiagnostic, when complications have developed or are clinically suspected, or when intracardiac device leads are present.IB
TTE and/or TEE are recommended for re-evaluation of patients with IE who have a change in clinical signs or symptoms (eg, new murmur, embolism, persistent fever, HF, abscess, or atrioventricular heart block) and in patients at high risk of complications (eg, extensive infected tissue/large vegetation on initial echocardiogram or staphylococcal, enterococcal, or fungal infections).IB
Intraoperative TEE is recommended for patients undergoing valve surgery for IE.IB
TEE is reasonable to diagnose possible IE in patients with
S. aureus bacteremia without a known source.
IIaB
TEE is reasonable to diagnose IE of a prosthetic valve in
the presence of persistent fever without bacteremia or a
new murmur.
IIaB
TEE might be considered to detect concomitant staphylococcal IE in nosocomial S. aureus bacteremia with a known portal of entry from an extracardiac source.IIbB
Medical Therapy
Patients with IE should be evaluated and managed with consultation of a multispecialty Heart Valve Team including an infectious disease specialist, cardiologist, and cardiac surgeon. In surgically managed patients, this team should also include a cardiac anesthesiologist.IB
Appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and infectious disease consultants.IB
It is reasonable to temporarily discontinue anticoagulation in patients with IE who develop CNS symptoms compatible with embolism or stroke, regardless of other indications for anticoagulation.IIaB
Temporary discontinuation of VKA anticoagulation might be considered in patients receiving VKA anticoagulation at the time of IE diagnosis.IIbB
Patients with known VHD should NOT receive antibiotics before blood cultures are obtained for unexplained fever.III: HarmC
Surgical Therapy
Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists.IB
Early surgerya is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF.IB
Early surgerya is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms.IB
Early surgerya is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions.IB
Early surgerya for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5-7 days after onset of appropriate antimicrobial therapy.IB
Surgery is recommended for patients with PVE and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection.IC
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as part of the early management plan in patients with IE with documented infection of the device or leads.IB
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection.IIaB
Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE.IIaC
Early surgerya is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy.IIaB
Early surgerya may be considered in patients with NVE who exhibit mobile vegetations >10 mm in length (with or without clinical evidence of embolic phenomena).IIbB

a Early surgery is defined as during initial hospitalization before completion of a full therapeutic course of antibiotics.

Table 32. Diagnosis of IE According to Proposed Modified Duke Criteria

Definite IE
Pathologic criteria
  • Microorganisms demonstrated by culture or histologic examination of a vegetation, a vegetation that has embolized, or an intracardiac abscess specimen; or
  • Pathologic lesions: vegetation or intracardiac abscess confirmed by histologic examination showing active endocarditis
Clinical criteria
  • 2 major criteria; or
  • 1 major criterion and 3 minor criteria; or
  • 5 minor criteria
Possible IE
  • 1 major criterion and 1 minor criterion or
  • 3 minor criteria
Rejected
  • Firm alternative diagnosis explaining evidence of IE; or
  • Resolution of IE syndrome with antibiotic therapy for <4 d; or
  • No pathologic evidence of IE at surgery or autopsy, with antibiotic therapy for <4 d; or
  • Does not meet criteria for possible IE as listed above

Table 33. Modified Duke Criteria for Diagnosis of IE

Major Criteria1. Blood culture positive for IE Typical microorganisms consistent with IE from 2 separate blood cultures:
  • Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), S. aureus; or community-acquired enterococci, in the absence of a primary focus; or
Microorganisms consistent with IE from persistently positive blood cultures,
defined as follows:
  • At least 2 positive cultures of blood samples drawn 12 h apart or
  • All of 3 or a majority of ≥4 separate positive blood cultures (with first and last samples drawn at least 1 h apart) or
  • Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800
2. Evidence of endocardial involvement
  • Echocardiogram positive for IE defined as follows:
    • Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative
      anatomic explanation;
    • Abscess; or
    • New partial dehiscence of prosthetic valve
  • New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)
Minor Criteria1. Predisposition, predisposing heart condition, or injection drug use
2. Fever, temperature >38° C (100.4° F)
3. Vascular phenomena, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
4. Immunologic phenomena: glomerulonephritis, Osler’s nodes, Roth’s spots, and rheumatoid factor
5. Microbiologic evidence: positive blood culture but does not meet a major criterion as noted abovea or serologic evidence of active infection with organism consistent with IE
a Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause IE.

Pregnancy and VHD


Figure 10. Anticoagulation of Pregnant Patients With Mechanical Valves


Table 34. Pregnancy and VHD

RecommendationsCORLOE
Native Valve Stenosis
All patients with suspected valve stenosis should undergo a clinical evaluation and TTE before pregnancy.IC
All patients with severe valve stenosis (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.IC
All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy about the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair.IC
Pregnant patients with severe valve stenosis (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients during pregnancy.IC
Exercise testing is reasonable in asymptomatic patients
with severe AS (aortic velocity ≥4.0 m/s or
ΔPmean ≥40 mm Hg, stage C) before pregnancy.
IIaC
Medical Therapy
Anticoagulation should be given to pregnant patients with MS and AF unless contraindicated.IC
Use of beta blockers as required for rate control is reasonable for pregnant patients with MS in the absence of contraindication if tolerated.IIaC
Use of diuretics may be reasonable for pregnant patients with MS and HF symptoms (stage D).IIbC
ACE inhibitors and ARBs should NOTbe given to pregnant patients with valve stenosis.III: HarmB
Intervention
Valve intervention is recommended before pregnancy for symptomatic patients with severe AS (aortic velocity ≥4.0 m/s or ΔPmean ≥40 mm Hg, stage D).IC
Valve intervention is recommended before pregnancy for symptomatic patients with severe MS (MVA ≤1.5 cm2, stage D).IC
PMBC is recommended before pregnancy for asymptomatic patients with severe MS (MVA ≤1.5 cm2, stage C)
who have valve morphology favorable for PMBC.
IC
Valve intervention is reasonable before pregnancy for asymptomatic patients with severe AS (aortic velocity
≥4.0 m/s or ΔPmean ≥40 mm Hg, stage C).
IIaC
PMBC is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) with valve morphology favorable for PMBC who remain symptomatic with NYHA class III-IV HF symptoms despite medical therapy.IIaB
Valve intervention is reasonable for pregnant patients with severe MS (MVA ≤1.5 cm2, stage D) and valve morphology not favorable for PMBC only if there are refractory NYHA class IV HF symptoms.IIaC
Valve intervention is reasonable for pregnant patients with severe AS (ΔPmean ≥40 mm Hg, stage D) only if there is hemodynamic deterioration or NYHA class III-IV HF symptoms.IIaB
Valve operation should NOT be performed in pregnant patients with valve stenosis in the absence of severe HF symptoms.III:HarmC
Native Valve Regurgitation
All patients with suspected valve regurgitation should undergo a clinical evaluation and TTE before pregnancy.IC
All patients with severe valve regurgitation (stages C and D) should undergo prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy.IC
All patients referred for a valve operation before pregnancy should receive prepregnancy counseling by a cardiologist with expertise in managing patients with VHD during pregnancy regarding the risks and benefits of all options for operative interventions, including mechanical prosthesis, bioprosthesis, and valve repair.IC
Pregnant patients with severe regurgitation (stages C and D) should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in managing high-risk cardiac patients.IC
Exercise testing is reasonable in asymptomatic patients with severe valve regurgitation (stage C) before pregnancy.IIaC
ACE inhibitors and ARBs should NOT be given to pregnant patients with valve regurgitation.III: HarmB
Intervention
Valve repair or replacement is recommended before pregnancy for symptomatic women with severe valve regurgitation
(stage D).
IC
Valve operation for pregnant patients with severe valve regurgitation is reasonable only if there are refractory NYHA class IV HF symptoms (stage D).IIaC
Valve repair before pregnancy may be considered in the asymptomatic patient with severe MR (stage C) and a valve suitable for repair, but only after detailed discussion with the patient about the risks and benefits of the operation and its outcome on future pregnancies.IIbC
Valve operations should NOT be performed in pregnant patients with valve regurgitation in the absence of severe intractable HF symptoms.III:HarmC
Prosthetic Valves
All patients with a prosthetic valve should undergo a clinical evaluation and baseline TTE before pregnancy.IC
All patients with a prosthetic valve should undergo prepregnancy counseling by a cardiologist with expertise
in managing patients with VHD during pregnancy.
IC
TTE should be performed in all pregnant patients with a prosthetic valve if not done before pregnancy.IC
Repeat TTE should be performed in all pregnant patients with a prosthetic valve who develop symptoms.IC
TEE should be performed in all pregnant patients with a mechanical prosthetic valve who have prosthetic valve obstruction or experience an embolic event.IC
Pregnant patients with a mechanical prosthesis should be monitored in a tertiary care center with a dedicated Heart Valve Team of cardiologists, surgeons, anesthesiologists, and obstetricians with expertise in the management of high-risk cardiac patients.IC
Medical Therapy
Therapeutic anticoagulation with frequent monitoring is recommended for all pregnant patients with a mechanical prosthesis.IB
Warfarin is recommended in pregnant patients with a mechanical prosthesis to achieve a therapeutic INR in the second and third trimesters.IB
Discontinuation of warfarin with initiation of IV UFH (with an aPTT >2 times control) is recommended before planned vaginal delivery in pregnant patients with a mechanical prosthesis.IC
Low-dose ASA (75-100 mg) once per day is recommended for pregnant patients in the second and third trimesters with either a mechanical prosthesis or bioprosthesis.IC
Continuation of warfarin during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin to achieve a therapeutic INR is ≤5 mg daily after full discussion with the patient about risks and benefits.IIaB
Dose-adjusted LMWH at least 2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR.IIaB
Dose-adjusted continuous IV UFH (with aPTT ≥2 times control) during the first trimester is reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is >5 mg daily to achieve a therapeutic INR.IIaB
Dose-adjusted LMWH ≥2 times per day (with a target anti-Xa level of 0.8-1.2 U/mL, 4-6 hours postdose) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR.IIbB
Dose-adjusted continuous infusion of UFH (with aPTT ≥2 times control) during the first trimester may be reasonable for pregnant patients with a mechanical prosthesis if the dose of warfarin is ≤5 mg daily to achieve a therapeutic INR.IIbB
LMWH should NOT be administered to pregnant patients with mechanical prostheses unless anti-Xa levels are monitored 4-6 hours after administration.III:HarmB

Surgical Considerations in Patients With CAD


Figure 11. Evaluation and Management of CAD in Patients Undergoing Valve Surgery


Table 35. Surgical Considerations in Patients With VHD

RecommendationsCORLOE
Evaluation of Coronary Anatomy
Coronary angiography is indicated before valve intervention in patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including men age >40 years and postmenopausal women).IC
Coronary angiography should be performed as part of the evaluation of patients with chronic severe secondary MR.IC
Surgery without coronary angiography is reasonable for patients having emergency valve surgery for acute valve regurgitation, disease of the aortic sinuses or ascending aorta, or IE.IIaC
CT coronary angiography is reasonable to exclude the presence of significant obstructive CAD in selected patients with a low/intermediate pretest probability of CAD. A positive coronary CT angiogram (the presence of any epicardial CAD) can be confirmed with invasive coronary angiography.IIaB
Intervention for CAD
CABG or PCI is reasonable in patients undergoing valve repair or replacement with significant CAD (≥70% reduction in luminal diameter in major coronary arteries or ≥50% reduction in luminal diameter in the left main coronary artery).IIaC
Intervention for AF
A concomitant maze procedure is reasonable at the time of MV repair or replacement for treatment of chronic, persistent AF.IIaC
A full biatrial maze procedure, when technically feasible, is reasonable at the time of MV surgery, compared with a lesser ablation procedure, in patients with chronic, persistent AF.IIaB
A concomitant maze procedure or pulmonary vein isolation may be considered at the time of MV repair or replacement in patients with paroxysmal AF that is symptomatic or associated with a history of embolism on anticoagulation.IIbC
A concomitant maze procedure or pulmonary vein isolation may be considered at the time of cardiac surgical procedures other than MV surgery in patients with paroxysmal or persistent AF that is symptomatic or associated with a history of emboli on anticoagulation.IIbC
Catheter ablation for AF should NOT be performed in patients with severe MR when mitral repair or replacement is anticipated, with preference for the combined maze procedure plus MV repair.III: HarmB

Table 36. Noncardiac Surgery in Patients With VHD

RecommendationsCORLOE
Noncardiac Surgery in Patients With VHD
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AS.IIaB
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe MR.IIaC
Moderate-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable to perform in patients with asymptomatic severe AR and a normal LVEF.IIaC
Moderate-risk elective noncardiac surgery in patients with appropriate intraoperative and postoperative hemodynamic monitoring may be reasonable to perform in asymptomatic patients with severe MS if valve morphology is not favorable for PMBC.IIbC

Applying Classification of Recommendations and Level of Evidence

 Size of Treatment Effect
Estimate of Certainty (precision) of Treatment Effect CLASS I
Benefit >>> Risk

Procedure/Treatment
SHOULD be performed/administered
CLASS IIa
Benefit >> Risk

Additional studies with
focused objectives needed
IT IS REASONABLE
to perform procedure/administer treatment
CLASS IIb
Benefit ≥ Risk

Additional studies with broad objectives needed; additional registry data would be helpful
Procedure/Treatment
MAY BE CONSIDERED
CLASS III
No Benefit or CLASS III
Harm
 Procedure/
Test
Treatment
COR III:
No benefit
Not HelpfulNo Proven Benefit
COR III:
Harm
Excess Cost w/o Benefit
or Harmful
Harmful to Patients
LEVEL A
Multiple populations evaluateda

Data derived from multiple randomized clinical trials or meta-analyses
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trails or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials of meta-analyses
LEVEL B
Limited populations evaluateda

Data derived from a single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C
Very limited populations evaluateda

Only consensus opinion of experts, case studies, or standards of care
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard of care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard of care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard of care
 Suggested phrases for writing recommendations:should
is recommended
is indicated
is useful/effective/beneficial
is reasonable
can be useful/effective/beneficial
is probably recommended or indicated
may/might be considered
may/might be reasonable
usefulness/effectiveness is unknown/unclear/uncertain or not well established
COR III: No Benefit
is not recommended
is not indicated
should not be performed/administered/other
is not useful/beneficial/effective
COR III: Harm
potentially harmful
causes harm
associated with excess morbidity/mortality
should not be performed/ administered/other
Comparative effectiveness phrasesb:treatment/strategy A
is recommended/indicated in preference
to treatment B

treatment A should be chosen over treatment B
treatment/strategy A is probably recommended/indicated in preference to treatment B

it is reasonable to choose
treatment A over treatment B
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even when randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.a Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior MI, history of HF, and prior aspirin use.
b For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

Abbreviations

2D, 2-dimensional; 3D, 3-dimensional; ΔP, pressure gradient; ACE, angiotensin-converting enzyme; AF, atrial fibrillation; aPTT, activated partial thromboplastin time; AR, aortic regurgitation; ARB, angiotensin-receptor blocker; AS, aortic stenosis; ASA, aspirin; AVA, aortic valve area; AVAi, aortic valve area indexed to body surface area; AVR, aortic valve replacement; BID, twice daily; BP, blood pressure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CKD, chronic kidney disease; CMR, cardiac magnetic resonance; CNS, central nervous system; COR, Class of Recommendation; CRT, cardiac resynchronization therapy; CT, computed tomography; CW, continuous wave; DLCO2, diffusion capacity for carbon dioxide; DSE, dobutamine stress echocardiography; ECG, electrocardiogram; ERO, effective regurgitant orifice; ETT, exercise treadmill test; FEV1, forced expiratory volume in 1 second; GI, gastrointestinal; GDMT, guideline-directed medical therapy; HF, heart failure; HIV, human immunodeficiency virus; ICD, implantable cardioverter-defibrillator; IE, infective endocarditis; IM, intramuscularly; INR, international normalized ratio; IV, intravenous; IVC, inferior vena cava; LA, left atrium; LMWH, low-molecular-weight heparin; LOE, Level of Evidence; LV, left ventricular; LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic dimension; LVESD, left ventricular end-systolic dimension; LVOT, left ventricular outflow tract; MI, myocardial infarction; MR, mitral regurgitation; MS, mitral stenosis; MV, mitral valve; MVA, mitral valve area; MVR, mitral valve replacement; N/A, not applicable; NVE, native valve endocarditis; NYHA, New York Heart Association; PA, pulmonary artery; PASP, pulmonary artery systolic pressure; PCI, percutaneous coronary intervention; PCWP, pulmonary capillary wedge pressure; PHTN, pulmonary hypertension; PMBC, percutaneous mitral balloon commissurotomy; PO, by mouth; PR, pulmonic regurgitation; PROM, predicted risk of mortality; PVE, prosthetic valve endocarditis; QD, once daily; RA, right atrium; RF, regurgitant fraction; RVol, regurgitant volume; RV, right ventricular; RVH, right ventricular hypertrophy; RVOT, right ventricular outflow tract; Rx, therapy; S. aureus, Staphylococcus aureus; SC, subcutaneous; T½, half-life; spp, species; STS, Society of Thoracic Surgeons; TA, tricuspid annular; TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography; TR, tricuspid regurgitation; TS, tricuspid stenosis; TTE, transthoracic echocardiography/echocardiogram; TV, tricuspid valve; TVR, tricuspid valve replacement; UFH, unfractionated heparin; VHD, valvular heart disease; VKA, vitamin K antagonist; Vmax, maximal velocity

Source

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol
2014;63:e57–185. Copublished in Circulation 2014;129:e521-e643.

Disclaimer

This Guideline attempts to define principles of practice that should produce high-quality patient care. It is applicable to specialists, primary care practitioners, and providers at all levels. This Guideline should not be considered exclusive of other methods of care reasonably directed at obtaining the same results. The ultimate judgment concerning the propriety of any course of conduct must be made by the clinician after consideration of each individual patient situation.

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